A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures.

BACKGROUND: Anal fissure is a common painful condition affecting the anal canal. The majority of acute fissures heal spontaneously. However, some of these acute fissures do not resolve but become chronic. Chronic anal fissures were traditionally treated by anal dilation or by lateral sphincterotomy. However, both of these surgical treatments may cause a degree of incontinence in up to 30% of patients. Several recent trials have shown that nitric oxide donors such as glyceryl trinitrate (GTN) can reduce sphincter pressure and heal up to 70% of chronic fissures. AIM: This study addressed the dose-response to three different concentrations of GTN ointment compared with placebo in a double blind randomised controlled trial. METHOD: A double blind, multicentre, randomised controlled trial was set up to compare placebo ointment against three active treatment arms (0.1%, 0.2%, and 0.4% GTN ointment applied at a dose of 220 mg twice daily) in chronic anal fissures. The primary end point was complete healing of the fissure. RESULTS: Two hundred patients were recruited over an eight month period from 18 centres. After eight weeks of treatment the healing rate in the placebo group was 37.5% compared with 46.9% for 0.1%, 40.4% for 0.2%, and 54.1% for 0.4% GTN. None was significantly better than the placebo response. A secondary analysis excluded fissures without secondary criteria for chronicity. Healing rates were then found to be 24% in the placebo group compared with 50% in the 0.1% GTN group, 36% in the 0.2% group, and 57% in the 0.4% GTN group. These values were statistically significantly different for the placebo group compared with 0.1% GTN, 0.4% GTN, and for the GTN treated group as a whole. CONCLUSIONS: The results of this study have demonstrated the significant benefit of topical GTN when applied to patients suffering from chronic anal fissures but acute fissures showed a tendency to resolve spontaneously. The high proportion of fissures which healed in the placebo group suggests that the definition of "chronicity" needs to be reassessed. Further studies are required to confirm the optimal therapeutic strategy.

[Intraoperative radiotherapy as part of the treatment concept of soft tissue sarcomas]. / Die intraoperative Strahlentherapie im Behandlungskonzept von Weichteilsarkomen.

The therapy of soft tissue sarcomas is not uniform. The goal of treatment for soft tissue sarcomas is surgical resection with negative microscopic margins. Other therapy options are pre-, intra-, or postoperative radiotherapy as well as neoadjuvantor adjuvant chemotherapy with different drugs, systemic or under local perfusion of the limb. If a margin-free surgical resection is not possible, intraoperative radiation therapy (IORT) offers the possibility for treatment of sites at high risk for local recurrence. The goal of this collaborating study of the Orthopedic University Hospital of Heidelberg and the department of Radio-Oncology of the University Hospital of Heidelberg is to observe the influence of IORT on the rate of local recurrence, complications, metastases, and survival in another wise unchanged tumor management. From 1960 to 1998,78 patients were treated for soft tissue sarcomas; 26 of 78 patients underwent intraoperative radiation and 52 patients were treated without intraoperative radiation. We found a recurrence rate of 15% in the IORT group and 29% in the non-IORT group. No difference for survival or distant recurrence was found, also no difference in early postoperative complication rate, but a higher rate of late complications after IORT (34% vs 7%) was remarkable. We think intraoperative radiation allows better local control and for that reason IORT is integrated into our therapeutic concept. Its influence on survival and distant metastases needs further investigations.

[Malignant lymphoma of the small intestine as a cause of small intestine perforation]. / Das maligne Dünndarmlymphom als Ursache der spontanen Dünndarmperforation.

The malignant non-Hodgkin-lymphoma is the main cause of spontaneous extraduodenal small intestine perforation. This rare incidence occurs as a consequence of an enteropathic associated affection manifested extranodally, mostly in the higher part of the jejunum. The diagnosis is made after a spontaneous perforation. The risk of a recurrent perforation is high. In a female patient we made the diagnosis not before resecting the small intestine.

Mucoid cytoplasmic inclusions in urothelial carcinomas.

To date, mucoid cytoplasmic inclusions in urothelial carcinomas have rarely been noted. However, we were impressed by the fact that these corpuscles are readily detectable in numerous urothelial neoplasms. Therefore, a histologic analysis of 100 cases of urothelial carcinomas was performed. Overall, 37 cases revealed periodic acid-Schiff-positive cytoplasmic inclusions. These were observed in 14% of grade 1, 49% of grade 2, and 63% of grade 3 carcinomas. The inclusions were histochemically, immunohistochemically, and ultrastructurally identified as cytoplasmic deposits of mucoid materials. Two types of deposits, condensed and noncondensed, could be distinguished. The demonstration of mucoid deposits in otherwise poorly differentiated metastatic carcinomas may be of some differential diagnostic importance insofar as urothelial carcinoma has to be considered as the possible primary tumor.

Air cooling for an interstitial microwave hyperthermia antenna: theory and experiment.

Microwave antennas are inserted through brachytherapy catheters implanted in a tumor to deliver interstitial hyperthermia cancer therapy. Theoretical calculations show that a cooling rate on the order of 0.1 W/cm length of catheter will significantly improve the radial uniformity of the temperature distribution of single antennas or arrays. Experiments and theoretical calculations show that air passing through the annulus between the antenna and the catheter at 10 L/min or less will produce such a cooling rate in a 2.2-mm OD catheter that has both ends accessible. To maintain uniformity of cooling rate along the catheter, it is better to control the cooling rate by preheating the air entering the catheter to 30-40 degrees C than it is to control the flow rate of room-temperature air. Ohmic heating of the antenna feedline does not confound the air cooling action significantly.

Electrodissection tonsillectomy.

A prospective, double-blind study was undertaken to compare the technique of removing tonsils using cold dissection with selective cauterization vs electrocautery dissection. The length of the procedure, blood loss, degree of pharyngeal pain, otalgia, and incidence of postoperative hemorrhage was recorded for 106 consecutive patients. In addition, our experience in performing the electrodissection tonsillectomy in 2431 patients is reviewed. Electrodissection tonsillectomy is a safe and effective procedure that offers several advantages over that of cold dissection using selective cautery.

[Spontaneous remission in disseminated histiocytosis X]. / Spontanremission bei disseminierter Histiozytosis X.

An 8 months old girl presented with biopsy-proven, disseminated histiocytosis X affecting at least two organ systems. Within one year there was spontaneous regression of the disease lasting for 10 years until today. Considering this case and others from literature the necessity of aggressive chemotherapy in selected cases is discussed.

[Granular cell tumor of the orbit]. / Der Granularzelltumor in der Orbita.

The authors report on the rare case of the intraorbital localisation of a granular cell tumour. Nature, histogenesis and biological behaviour of this lesion are discussed. The therapeutical consequences are presented.

Unusual cause of recurrent arterial embolism: floating thrombus in the aortic arch surgically removed under hypothermic cardiocirculatory arrest.

A 46-year-old fully active, asymptomatic man suffered two episodes of major peripheral arterial embolism within 2 months. Heart disease was ruled out by appropriate investigations. Further diagnostic evaluation (angiography, CAT scan) revealed the extremely rare finding of a "floating mass" in the transverse aortic arch suspected to be the source of embolization. This mass was successfully removed using the technique of hypothermic cardiocirculatory arrest. The histological diagnosis was an aged intraluminal thrombus and moderate atherosclerosis of the thoracic aorta. For prevention of recurrent arterial embolism in cases without an initially apparent cause and site of origin, a thorough diagnostic, and in a given patient, an aggressive surgical approach for the elimination of the embolic source are advocated.

[Atypical congenital dyserythropoietic anemia]. / Atypische kongenitale dyserythropoietische Anämie.

The case is presented of a 26-year-old male patient suffering from chronic anemia since infancy. At age 12 (1972), congenital dyserythropoietic anemia (CDA) was diagnosed which could not be grouped with one of the three known variants of CDA. From onset the disease was complicated by thrombocytopenia with severe hemorrhagic diathesis. After splenectomy (1972) an extremely enlarged accessory spleen was removed in 1985 disclosing, histologically, excessively developed extramedullary hematopoiesis. Since bone marrow biopsy showed massive hyperplasia, the cellular phase of a myeloproliferative syndrome could not be excluded by histology alone.--Only a few cases of CDA with involvement of granulocytes and megakaryocytes have been reported so far. It is not clear whether or not they should be classed with CDA. In any event, involvement of granulopoiesis and/or thrombopoiesis indicates a genetic lesion of very early precursors, perhaps stem cells. It is proposed that such variants would be more correctly designated "congenital dyshematopoietic syndromes".

Evaluation and management of a carcinoma arising in a thyroglossal duct cyst.

Thyroglossal duct remnants are the most common congenital cystic lesions of the neck; however, a carcinoma arising in these structures is rare. Two new cases of a papillary adenocarcinoma arising in a thyroglossal duct cyst are presented. Preoperative evaluation, operative management, and postoperative care are discussed. Initial evaluation consisting of a thorough head and neck examination, palpation of the thyroid gland, thyroid function tests, and selective use of thyroid imaging is recommended. Removal of the cyst and tract in the manner described by Sistrunk is advocated. If an adenocarcinoma is found in the cyst and if a carcinoma is found in the thyroid gland or a thyroid scan reveals a nodule, a total thyroidectomy is recommended. A modified neck dissection and total thyroidectomy is advocated for cervical metastases. Postoperatively, thyroid suppression and long-term follow-up are encouraged. A squamous cell carcinoma arising in a thyroglossal duct remnant appears more aggressive and requires complete excision and, for confirmed cervical metastases, radical neck dissection and postoperative radiation therapy.

[Non-ocular, malignant secondary tumor following spontaneous healing of a retinoblastoma ("retinoma", "retinocytoma")]. / Nicht-okulärer, maligner Zweittumor nach Spontanheilung eines Retinoblastoms ("Retinom", "Retinozytom").

In a 47-year-old patient, the father of a child with bilateral retinoblastoma, three retinomas or retinocytomas were observed in the right eye, which had never been treated, in the course of a routine checkup. The left eye had been enucleated at age three-and-a-half because of a tumor of unknown etiology. At age 55 the patient died of lung cancer. The autopsy revealed a metastasized small-cell bronchial carcinoma. Histopathological examination of the right eye showed, in the region where the tumors had been observed clinically, merely disorganized retinal tissue with proliferations of pigment epithelium in some areas, and well-differentiated retinoblastomas in others. Tumor regression and differentiation appear to be the mechanisms responsible for spontaneous healing of the retinoblastoma. This case also emphasizes the threat posed by non-ocular secondary tumors to carriers of retinoblastoma genes.

Primary sclerosing cholangitis in children.

Primary sclerosing cholangitis (PSC) in eight children, five males and three females between the ages of 4 and 13 years, presented with minimal clinical symptoms and few signs of liver disease. Diagnosis was made by a highly characteristic histology in all and additional endoscopic retrograde cholangiography (ERC) in four patients. Six children suffered from concomitant inflammatory bowel disease (IBD). Laboratory abnormalities consisted of mild elevation of transaminases and alkaline phosphatase, with marked elevation of immunoglobulin G in seven and detection of anti-nuclear antibodies in four of the eight children. In all cases, needle liver biopsy specimens revealed portal tracts considerably expanded by edema and chronic inflammation diagnostic of nonsuppurative cholangitis and nonsuppurative fibrosing pericholangitis. ERC showed decreased arborization in the whole biliary tree. In two patients, changes were confined to the intrahepatic portion of the biliary tract. No specific drug therapy was given to our patients. Those with concomitant IBD were treated with salazosulfapyridine (SASP). The clinical course has been mild in all patients up to now. It is concluded that PSC may be much more frequent in childhood than was considered before, especially in children with IBD.